Value-based healthcare in ischemic stroke care: case-mix adjustment models for clinical and patient-reported outcomes.

BACKGROUND: Patient-Reported Outcome Measures (PROMs) have been proposed for benchmarking health care quality across hospitals, which requires extensive case-mix adjustment. The current study's aim was to develop and compare case-mix models for mortality, a functional outcome, and a patient-reported outcome measure (PROM) in ischemic stroke care. METHODS: Data from ischemic stroke patients, admitted to four stroke centers in the Netherlands between 2014 and 2016 with available outcome information (N = 1022), was analyzed. Case-mix adjustment models were developed for mortality, modified Rankin Scale (mRS) scores and EQ-5D index scores with respectively binary logistic, proportional odds and linear regression models with stepwise backward selection. Predictive ability of these models was determined with R-squared (R2) and area-under-the-receiver-operating-characteristic-curve (AUC) statistics. RESULTS: Age, NIHSS score on admission, and heart failure were the only common predictors across all three case-mix adjustment models. Specific predictors for the EQ-5D index score were sex (ß = 0.041), socio-economic status (ß = - 0.019) and nationality (ß = - 0.074). R2-values for the regression models for mortality (5 predictors), mRS score (9 predictors) and EQ-5D utility score (12 predictors), were respectively R2 = 0.44, R2 = 0.42 and R2 = 0.37. CONCLUSIONS: The set of case-mix adjustment variables for the EQ-5D at three months differed considerably from the set for clinical outcomes in stroke care. The case-mix adjustment variables that were specific to this PROM were sex, socio-economic status and nationality. These variables should be considered in future attempts to risk-adjust for PROMs during benchmarking of hospitals.

Association between i.v. thrombolysis volume and door-to-needle times in acute ischemic stroke.

Centralization of intravenous thrombolysis (IVT) for acute ischemic stroke in high-volume centers is believed to improve the door-to-needle times (DNT), but limited data support this assumption. We examined the association between DNT and IVT volume in a large Dutch province. We identified consecutive patients treated with IVT between January 2009 and 2013. Based on annualized IVT volume, hospitals were categorized as low-volume (≤ 24), medium-volume (25-49) or high-volume (≥ 50). In logistic regression analysis, low-volume hospitals were used as reference category. Of 17,332 stroke patients from 11 participating hospitals, 1962 received IVT (11.3 %). We excluded 140 patients because of unknown DNT (n = 86) or in-hospital stroke (n = 54). There were two low-volume (total 101 patients), five medium-volume (747 patients) and four high-volume hospitals (974 patients). Median DNT was shorter in high-volume hospitals (30 min) than in medium-volume (42 min, p < 0.001) and low-volume hospitals (38 min, p < 0.001). Patients admitted to high-volume hospitals had a higher chance of DNT < 30 min (adjusted OR 3.13, 95 % CI 1.70-5.75), lower risk of symptomatic intracerebral hemorrhage (adjusted OR 0.39, 95 % CI 0.16-0.92), and a lower mortality risk (adjusted OR 0.45, 95 % CI 0.21-1.01), compared to low-volume centers. There was no difference in DNT between low- and medium-volume hospitals. Onset-to-needle times (ONT) did not differ between the groups. Hospitals in this Dutch province generally achieved short DNTs. Despite this overall good performance, higher IVT volumes were associated with shorter DNTs and lower complication risks. The ONT was not associated with IVT volume.

A process evaluation of a stroke-specific follow-up care model for stroke patients and caregivers; a longitudinal study.

BACKGROUND: There is a need for follow-up care after stroke, but there is no consensus about the way to organise it. An intervention providing follow-up care for stroke patients and caregivers showed favourable effects on the level of social activities, but no other effects were found. The intervention consists of a maximum of five home visits to patients and caregivers during a period of 18 months post-discharge. The home visits are conducted by a stroke care coordinator (SCC) using a structured assessment tool. The objective of this study was to examine process-related factors that could have influenced the effectiveness of the intervention. METHODS: 77 stroke patients, 59 caregivers and 4 SCCs participated in the study. Data on the organisational characteristics of and the satisfaction with the intervention were collected by means of structured assessments, interviews and self-administered questionnaires at 1, 6, 12 and 18 months of follow-up. The intervention was provided between April 2008 and June 2011. RESULTS: Patients received an average of 3.8 home visits (SD 1.4) and 55% of them had a follow-up period of a maximum of 18 months. There were 1074 problems identified and the SCCs initiated 363 follow-up care and referral options. Stroke patients and caregivers were very satisfied with the intervention. The SCCs were satisfied with the assessment tool, but would like to see a structured referral system. CONCLUSIONS: The intervention was only partially performed in accordance with the protocol and was positively evaluated by patients, caregivers and SCCs. It is recommended to add a structured referral system to the intervention.

Effect of a stroke-specific follow-up care model on the quality of life of stroke patients and caregivers: A controlled trial.

OBJECTIVE: To evaluate the effectiveness of a stroke-specific follow-up care model on quality of life for stroke patients, being discharged home, and their caregivers. DESIGN: A non-randomized, controlled trial, comparing an intervention group with a control group (usual care). SUBJECTS: Stroke patients and their caregivers. METHODS: Intervention involved 5 home visits by a stroke care coordinator over a period of 18 months, using a structured assessment tool. Outcome measures were conducted at baseline (T0) and every 6 months thereafter (T6, T12 and T18) in the domains of quality of life (primary), activities of daily living, social activities, depression, anxiety and caregiver strain. RESULTS: The intervention group (n = 62) had significantly increased its social activities after 18 months, whereas the control group (n = 55) showed significantly decreased levels of social activities. In the first 6 months, levels of depression decreased significantly in caregivers of the intervention group. No differences were found for quality of life and the other outcome measures. CONCLUSION: The intervention was not effective in improving quality of life, but was effective in improving levels of social activities. The intervention may have focussed too much on screening for stroke-related problems and not as much on adequate follow-up care and referral.

Variation in clinical practice of intravenous thrombolysis in stroke in the Netherlands.

In the Netherlands in 2010, 11% of patients with ischemic stroke received intravenous thrombolysis (IVT), varying from 4 to 26% between hospitals. The aim of this study was to investigate variation in clinical practice and organization of IVT in relationship to performance and outcome. In all 84 Dutch hospitals performing IVT, a stroke neurologist was approached using a web-based survey. The response rate was 82%. The study showed considerable variation. For example, door-to-needle time ranged from 25 to 80 min. High blood pressure was actively lowered before performing IVT by 57% of neurologists, while 35% chose to wait. 28% started IVT without knowledge of laboratory results. Better follow-up data are needed to see whether this variation results in differences in outcome.

The feasibility and test-retest reliability of the Dutch Swal-Qol adapted interview version for dysphagic patients with communicative and/or cognitive problems.

PURPOSE: The adaptation of the Dutch Swal-Qol questionnaire to an interview format suitable for dysphagic patients with communicative and/or cognitive problems and evaluation of the feasibility and test-retest reliability. METHODS: An observational study with two measurements within a 2-week time period in a sample of 57 stroke patients with dysphagia in a nursing home environment. The interview version of the Swal-Qol was evaluated in the total group and in subgroups of patients with and without communicative and/or cognitive problems. RESULTS: The constructed interview version was considered feasible from an expert's and patient's point of view. The overall score and seven subscales of the Swal-Qol showed an excellent test-retest reliability (k > 0.75), and two subscales were considered good (k > 0.60). CONCLUSIONS: This study showed that using a structured, and at the same time flexible, interview format tailored to the individual needs of stroke patients enhances the feasibility and does not compromise the test-retest reliability.

Not as transient: patients with transient ischaemic attack or minor stroke experience cognitive and communication problems; an exploratory study.

BACKGROUND: Patients with transient ischaemic attack (TIA) or minor stroke generally receive, besides secondary prevention, no regular follow up care after discharge directly home from the Emergency Room or TIA outpatient clinic; because it is believed that they will experience no consequences. OBJECTIVES: To explore whether the TIA and minor stroke patients have persistent problems due to the event. METHODS: This study has a cross-sectional, comparative non-randomized, exploratory design. Patients with TIA or minor stroke, not requiring hospital admission, and a control group of stroke patients, recently discharged home, were selected and interviewed with a questionnaire by telephone or home visit, between one and eight months after the event. Patients with angina pectoris (AP) were recruited as a second control group. RESULTS: Data showed that 51% of the TIA and minor stroke patients and 71% of the stroke patients experienced five or more problems, as opposed to 32% of patients with AP. Between 39 and 49% of the TIA, minor stroke and the stroke patients reported cognitive and communicative difficulties. Moreover, the TIA and minor stroke patients had more cognitive deficits (n = 27, 49%) and communicative limitations (n = 23, 42%) than the AP group (n = 7, 10% and n = 4, 6%, respectively). CONCLUSION: About half of the TIA and minor stroke patients experienced problems regarding cognition and communication, which were specific to the event. General practitioners should be aware of these potential problems and monitor patients regularly. Future research should focus on prognostic indicators to identify patients at risk.

Towards a better integrated stroke care: the development of integrated stroke care in the southern part of the Netherlands during the last 15 years (Special 10th Anniversary Edition paper).

INTRODUCTION: Stroke care is complex and often provided by various healthcare organisations. Integrated care solutions are needed to optimise stroke care. In this paper, we describe the development of integrated stroke care in the region of Maastricht during the last 15 years. DESCRIPTION OF INTEGRATED CARE CASE: Located in the south of the Netherlands, the region of Maastricht developed integrated stroke care to serve a population of about 180,000 people. Integration was needed to improve the continuity, coordination and quality of stroke care. The development of integrated care in Maastricht was a phased process. The last phase emphasized early discharge from hospital and assessing the best individual rehabilitation track in a specialized nursing home setting. DISCUSSION AND LESSONS LEARNED: The development and implementation of integrated stroke care in the region of Maastricht led to fewer days in hospital, more patients being directly admitted to the stroke unit and an earlier start of rehabilitation. The implementation of early discharge from the hospital and rehabilitation assessment in a nursing home led to some unforeseen problems and lessons learned.

Shifting stroke care from the hospital to the nursing home: explaining the outcomes of a Dutch case.

RATIONALE, AIMS AND OBJECTIVES: Supply chains can contribute to better care for stroke patients and more efficiency. However, such outcomes are hampered when links in the chain are weak. The article aims to further the knowledge about the causes and possible improvements of weak links thereby using theory about rules for action and routines (action patterns). METHOD: We executed a single case study of a chain of service delivery to stroke patients by a university hospital and a nursing home in the city of Maastricht, the Netherlands. Methods included document study, interviews, observations, process mapping, use of data matrices and performance of t-tests. RESULTS: In the case, the care delivery process in the chain was redesigned to improve the flow of patients and to reduce the length of hospital stay. Length of stay was reduced. However, transfer of patients from the hospital to the nursing home was hampered. At this weak link in the chain, the redesign clashed with the routines of hospital paramedics who did not want to work according to the redesign. CONCLUSIONS: The applied theory is useful to understand why a link in a supply chain is weak. Negotiations can be used to strengthen a link.

The cost effectiveness of an early transition from hospital to nursing home for stroke patients: design of a comparative study.

BACKGROUND: As the incidence of stroke has increased, its impact on society has increased accordingly, while it continues to have a major impact on the individual. New strategies to further improve the quality, efficiency and logistics of stroke services are necessary. Early discharge from hospital to a nursing home with an adequate rehabilitation programme could help to optimise integrated care for stroke patients.The objective is to describe the design of a non-randomised comparative study evaluating early admission to a nursing home, with multidisciplinary assessment, for stroke patients. The study is comprised of an effect evaluation, an economic evaluation and a process evaluation. METHODS/DESIGN: The design involves a non-randomised comparative trial for two groups. Participants are followed for 6 months from the time of stroke. The intervention consists of a redesigned care pathway for stroke patients. In this care pathway, patients are discharged from hospital to a nursing home within 5 days, in comparison with 12 days in the usual situation. In the nursing home a structured assessment takes place, aimed at planning adequate rehabilitation. People in the control group receive the usual care. The main outcome measures of the effect evaluation are quality of life and daily functioning. In addition, an economic evaluation will be performed from a societal perspective. A process evaluation will be carried out to evaluate the feasibility of the intervention as well as the experiences and opinions of patients and professionals. DISCUSSION: The results of this study will provide information about the cost effectiveness of the intervention and its effects on clinical outcomes and quality of life. Relevant strengths and weaknesses of the study are addressed in this article. TRIAL REGISTRATION: Current Controlled Trails ISRCTN58135104.

How predictive is the MMSE for cognitive performance after stroke?

Cognitive deficits are commonly observed in stroke patients. Neuropsychological testing is time-consuming and not easy to administer after hospital discharge. Standardised screening measures are desirable. The Mini-Mental State Examination (MMSE) is the test most widely applied to screen for cognitive deficits. Despite its broad use, its predictive characteristics after stroke have not been exhaustively investigated. The aim of this study was to determine whether the MMSE is able to adequately screen for cognitive impairment and dementia after stroke and whether or not the MMSE can predict further deterioration or recovery in cognitive function over time. To this end, we studied 194 first-ever stroke patients without pre-stroke cognitive deterioration who underwent MMSEs and neuropsychological test batteries at 1, 6, 12, and 24 months after stroke. The MMSE score 1 month after stroke predicted cognitive functioning at later follow-up visits. It could not predict deterioration or improvement in cognitive functioning over time. The cut-off score in the screening for 1 cognitive disturbed domain was 27/28 with a sensitivity of 0.72. The cut-off score in the screening for at least 4 impaired domains and dementia were 26/27 and 23/24 with a sensitivity of 0.82 and 0.96, respectively. The results indicated that the MMSE has modest qualities in screening for mild cognitive disturbances and is adequate in screening for moderate cognitive deficits or dementia in stroke patients 1 month after stroke. Poor performance on the MMSE is predictive for cognitive impairment in the long term. However, it cannot be used to predict further cognitive deterioration or improvement over time.

Bedside screening tests vs. videofluoroscopy or fibreoptic endoscopic evaluation of swallowing to detect dysphagia in patients with neurological disorders: systematic review.

AIM: This paper is a report of a systematic review conducted to determine the effectiveness and feasibility of bedside screening methods for detecting dysphagia in patients with neurological disorders. BACKGROUND: Dyspaghia affects 22-65% of patients with neurological conditions. Although there is a large variety of bedside tests to detect dysphagia, it is unknown which have the best psychometric properties and are feasible for nurses to use. DATA SOURCES AND REVIEW METHODS: An electronic database search was carried out using Medline (PubMed), Embase, CINAHL, and PsychLit, including all hits up to July 2008. The search terms were dysphagia, sensitivity, specificity, diagnosis, and screening. The methodological quality of included studies was assessed. RESULTS: Thirty-five out of 407 studies were included in the review. Eleven studies with sufficient methodological quality revealed that trial swallow tests using water had sensitivities between 27% and 85% and specificities between 63% and 88%. Trial swallow tests with different viscosities led to sensitivities ranging from 41% to 100% and specificities of 57% to 82%. Combining water tests with oxygen desaturation led to sensitivities between 73% and 98% and specificities between 63% and 76%. Single clinical features, such as abnormal gag, generally had low sensitivity and specificity. CONCLUSION: A water test combined with pulse oximetry using coughing, choking and voice alteration as endpoints is currently the best method to screen patients with neurological disorders for dysphagia. Further research is needed to establish the most effective standardized administration procedure for such a water test, and to assess the value of pulse oximetry, in addition to a trial swallow to detect silent aspiration.

Using business process redesign to reduce wait times at a university hospital in the Netherlands.

BACKGROUND: Business process redesign (BPR) has been applied to implement more customer-focused and cost-effective care. In 2002, two pilot projects to improve patient care processes for two specific patient groups were conducted at the Academic Medical Center, a 1,000-bed university hospital in Amsterdam. METHODS: The BPR consisted of process analysis, identification of bottlenecks and goals for redesign, selection of interventions, and evaluation of effects. After identifying and selecting interventions with the greatest expected benefits, changes were implemented and effects were evaluated. RESULTS: For gynecologic oncology patients, access time (from telephone call to first visit) was reduced from 14 days to < 7 days, and the proportion of patients who completed all diagnostic examinations within 14 days increased from 49% to 83%. For dyspnea patients, access time was reduced to < 6 days, and the number of visits was halved. DISCUSSION: Despite the fact that we applied the same approach in these two projects, the interventions turned out to be quite different. Whereas changes in communication and planning were sufficient to eliminate bottlenecks in the gynecologic oncology project, the dyspnea project required a radical redesign of processes. Experience since these projects suggests that process redesign may have only marginal impact when the greatest bottleneck occurs, as was the case for the two BPR projects, at the point of access to central diagnostic facilities.

Fifteen years medical information sciences: the Amsterdam curriculum.

OBJECTIVES: To inform the medical informatics community on the rational, goals, evolution and present contents of the Medical Information Sciences program of the University of Amsterdam and our achievements. METHODS: We elaborate on the history of our program, the philosophy, contents and organizational structure of the present-day curriculum. Besides, we describe the various didactic approaches in the program and the rational for these. Finally, we analyze the contents of our program in respect to the IMIA recommendations for dedicated programs in health and medical informatics. RESULTS AND CONCLUSIONS: Since its foundation in 1987, the program has undergone several major modifications. From a degree program following medical school it developed into a full-fledged, dedicated 4-year program on medical information sciences training high-school graduates for a master degree. The curriculum has been based from its outset within the University of Amsterdam-Faculty of Medicine. This organizational structure leaves ample opportunity for integration of the informatics-oriented components with the medical and health care-oriented components in the program. Student-centered approaches are heavily employed in the program, emphasizing students' critical appraisal and a style of life-long learning. Overall, our program follows the IMIA recommendations with slightly more focus on medicine and health care organization.

A multidisciplinary guideline for the acute phase of stroke: barriers perceived by Dutch neurologists.

RATIONALE, AIMS AND OBJECTIVES: Guidelines for stroke management should improve quality of care. Dissemination of guidelines, however, does not guarantee guideline adherence. The aim of this paper is to investigate barriers for guideline adherence to bring about suggestions for possible implementation strategies. METHOD: Questionnaire survey among all Dutch neurologists working on neurology wards in general hospitals during the year 2000 in The Netherlands. RESULTS: The neurologists expressed a high degree of agreement with the diagnostic and preventive recommendations, but expressed doubts with regard to the therapeutic recommendations, especially for the recombinant tissue plasminogen activator therapy. In general, barriers at the organizational and the multidisciplinary team level were most prominent. CONCLUSIONS: Active implementation of the guidelines seems necessary. Implementation strategies should be focused on the different sources of barriers: the caregiver, the patient and the organization of care.

Angiotensin-converting enzyme gene polymorphism, carotid intima-media thickness, and left ventricular mass index in adolescent hypertension.

PURPOSE: The aim of this study was to determine whether a positive correlation exists between the DD genotype of angiotensin-converting enzyme (ACE) and the carotid intima-media thickness (IMT) or left ventricular mass index (LVMI) in adolescents with hypertension. METHODS: We studied 120 hypertensive and 58 normotensive (control) adolescents. ACE gene polymorphism was determined by a standardized method. The IMT was measured in the common carotid arteries, and the LVMI was calculated on transthoracic echocardiography. The severity of hypertension was graded according to the results of ambulatory blood pressure monitoring as white coat, borderline, or proven hypertension. The association between ACE gene polymorphism and the obtained parameters was analyzed using analysis of variance and chi-square testing. RESULTS: Both the IMT and LVMI were higher in hypertensive than in control adolescents. In hypertensive subjects, no relationship was found between the different ACE genotypes and the IMT: the mean (+/- standard deviation) IMT in patients with the DD genotype was 0.57 +/- 0.11 mm; in those with the DI genotype, 0.53 +/- 0.01 mm; and in those with the II genotype, 0.55 +/- 0.01 mm. The LVMI was also similar in all 3 ACE genotypes: DD, 106.7 +/- 32.3 g/m(2); DI, 102.2 +/- 38.1 g/m(2); and II, 103.2 +/- 26.3 g/m(2). The severity of hypertension as assessed by ambulatory blood pressure monitoring was independent of the ACE genotype. CONCLUSIONS: Target-organ damage (left ventricular hypertrophy and carotid atherosclerosis) is detectable in adolescents with hypertension and, in those subjects, ACE genotype polymorphism is not correlated with the severity of target-organ damage as measured by IMT and LVMI.

Increased common carotid artery intima media thickness in adolescent hypertension: results from the Debrecen Hypertension study.

BACKGROUND: The aim of the present work was to investigate intima media thickness (IMT) in healthy and in hypertensive adolescents and its influencing factors. METHODS: 103 hypertensive and 58 healthy adolescents were studied. IMT was measured in the common carotid artery using B-mode ultrasonography. Additionally, laboratory parameters (blood glucose, cholesterol, triglycerides, HDL- and LDL-cholesterols) and left ventricular mass indices were obtained. RESULTS: IMT in the common carotid artery was higher in hypertensive adolescents (means +/- SD: 0.55 +/- 0.11 mm) than in healthy control subjects (0.48 +/- 0.08 mm, p < 0.001). Similarly, a higher left ventricular mass index was measured in hypertensive (103.2 +/- 30.6 g/m(2)) than in healthy teenagers (91.1 +/- 25.2 g/m(2), p < 0.001). In general, IMT in adolescents was associated with age, weight, body mass index, left ventricular mass index and average systolic and diastolic blood pressure values of the subjects. By assessing the multivariate association between IMT and other factors, intima-media thickness was only associated with age and left ventricular mass index of the hypertensive subjects and was independent from all the investigated factors in normotensive controls. CONCLUSIONS: Our data suggest an ongoing target-organ damage in adolescent hypertension. These patients need to be subjected to early diagnostic methods, treatment and a regular follow-up, in order to avoid severe clinical manifestations of secondary target-organ damage due to hypertension.

Assessment of cerebrovascular reserve capacity in asymptomatic and symptomatic hemodynamically significant carotid stenoses and occlusions.

BACKGROUND: Cerebrovascular reactivity measurements are believed to be a helpful tool for selecting patients who are at higher risk for hemodynamic strokes. The aim of this study was to compare cerebral vasoreactivity among patients suffering from internal carotid artery stenosis of different severity (asymptomatic stenosis, asymptomatic occlusion, symptomatic stenosis, symptomatic occlusion). METHODS: Sixty-two patients with asymptomatic and symptomatic internal carotid artery stenoses and occlusions underwent transcranial Doppler-acetazolamide tests. Absolute velocities of the middle cerebral arteries (MCAV), percent increases of the MCAV at different time points of the test (cerebrovascular reactivity, CVR) and maximal percent increase after administration of acetazolamide (cerebrovascular reserve, CRC) were compared on the affected and non-affected sides. Asymmetry indices (CRC (affected side)/CRC (non-affected side)) were compared between the groups of different severity of obstructive lesion. RESULTS: Resting MCAV was similar on both sides in all groups. A significant side-difference of the MCAV values after acetazolamide was observed only in the symptomatic groups. Difference of cerebrovascular reserve capacity between the affected and non-affected side was statistically significant only in the symptomatic groups (CRC symptomatic stenosis 36.6 +/- 20.9% vs. 71.1 +/- 27.9%, CRC symptomatic occlusion: 31.2 +/- 24.6% vs. 64.5 +/- 29.7%). Asymmetry index of the CRC was near to 1 in the asymptomatic stenosis group only, while in all the other groups this index referred to a significant hemispheric asymmetry of the vasoreactivity. CONCLUSIONS: Although in general cerebrovascular reserve capacity is compromised in cases of hemodynamically significant carotid lesions, there is a large individual variability within the subgroups. Further randomized studies are needed to clarify whether the clinical efficiency of carotid endarterectomy and extra-intracranial bypass may be improved by selecting the patients using hemodynamic criteria.

No correlation between impairment of cerebrovascular reserve capacity and electrophysiologically assessed severity of neuropathy in noninsulin-dependent diabetes mellitus.

INTRODUCTION: Microvascular abnormalities have an important role in the most frequent neurological complications of diabetes mellitus: neuropathy and cerebrovascular disorders. Severity of neuropathy as well as of cerebral microvascular damage can be quantitatively evaluated by instrumental methods like nerve conduction studies and transcranial Doppler. In the present study, we investigated whether a correlation exists between the severity of peripheral neuropathy and the impairment of cerebrovascular reserve capacity (CRC) in 20 patients with Type 2 diabetes mellitus. METHODS: CRC was measured by transcranial Doppler and defined as the maximal percentage increase in blood flow velocity in the middle cerebral artery within 20 min after an intravenous dose of 1000 mg of acetazolamide. Nerve conduction studies of the median, ulnar, peroneal, and sural nerves were performed. Severity of neuropathy was scored based on conduction velocities, amplitudes, and distal latencies. RESULTS: There was no correlation between the neuropathic score and CRC (R= .003, P= .99). Neither CRC nor the neuropathic score correlated significantly with age, duration of diabetes, and serum values of HbA(1c), glucose, insulin, von Willebrand factor, and alpha(2) - macroglobulin. Severity of neuropathy but not CRC correlated with microalbuminuria (R= .47, P= .038 and R= .14, P= .54). Improper treatment reflected by HbA(1c) >10% was associated with significantly more severe albuminuria, higher actual blood glucose level, higher von Willebrand factor activity, and marginally higher neuropathic score (21 vs. 13, P=.096), but was not associated with CRC (44% vs. 42%, P= .81). When duration of diabetes was dichotomized to 15 years and less or over 15 years, CRC was significantly smaller (35% vs. 50%, P= .036) and neuropathy was more severe in the subgroup with longer diabetes duration (19 vs. 11.5 points, P= .07). CONCLUSIONS: Although both CRC and peripheral nerve function are affected more severely in patients with long-lasting Type 2 diabetes mellitus, damage in the cerebrovascular system and in the long peripheral nerves occur independently. As in diabetes mellitus pathological changes in autonomic and large peripheral nerves develop simultaneously, decreased CRC in diabetic patients might be predominantly due to structural changes of resistance arteries or to metabolic than to neurogenic factors.